D0649186

Rural Health Network Development Program - Applicant Organization Name: Sanford Health of Northern Minnesota
Address: 1300 Anne St. NW, Bemidji, MN 56601
Facility Type: Rural Hospital
Website Address: SANFORDHEALTH.ORG

Designated Project Director & Designated Network Director
Project Director Name & Title: Erin Wichmann, Manager, Inpatient Case Management
Contact Phone Number: (218) 333-5563
Email Address: ERIN.WICHMANN@SANFORDHEALTH.ORG
Network Director: To be determined

Rural Health Network Development Project
Project Title: Stronger Together: Community Health Worker Hub Initiative
Project Goal(s): Establish a Community Health Worker Hub in the Bemidji region.
Focus Areas: Behavioral Health, Chronic Disease Mitigation and Prevention, and Diabetes Prevention.

Target Population
Patient population will include underserved and vulnerable populations in the counties listed above with a focus on the American Indian population.

Network Members
Sanford Health of Northern Minnesota (Rural Hospital), Leech Lake IHS, Beltrami County Health and Human Services (Public Health), PrimeWest Health (State Medicaid Agency), and Northwest Technical College.

Network Project Activities/Services
Stronger Together: Community Health Worker Hub Initiative will be a newly established network of care focused on identifying and addressing risk factors on the individual level as well as have an impact on the health of families in the Beltrami, Cass, Clearwater, and Hubbard County region. The project will centralize processes, systems, and resources to track those being served and tie payments for services to outcomes leading to population health management.

Expected Outcomes
The purpose of this proposal is to establish a Community Health Worker Hub based on the Pathways Community Health Model to address the following objectives as defined by HRSA:
- Improve access to care by establishing a well-coordinated network. Through integrated pathways, the hub will address gaps in care, identify and work with community partners to train and retain community health workers, create better workflows in order to reduce duplication of services, thereby improving the quality of care provided by member organizations of the CHW Hub.
- Expand capacity and services by creating effective systems through the development of knowledge, skills, structures, and pathways.
- Enhance outcomes by developing patient pathways and network development outcomes by establishing and strengthening the network's services, activities, or interventions.
- Sustainability by positioning the network to prepare for sustainable health programs through value-based care and population health management.

Capacity to Serve Rural Underserved Populations
Sanford Health of Northern Minnesota (SHNM) is itself a rural hospital, and 5 of the 6 network partners are located in rural designated areas within the project area. All 6 network partners have a long history of serving rural underserved populations. The target service area is comprised of entirely rural counties.

Funding Preference
Sanford Health of Northern Minnesota is requesting a funding preference based on qualification medically underserved community/populations (MUC/MUPS). All counties in the target service area (Beltrami, Cass, Clearwater, and Hubbard) are designated as medically underserved areas and are located in an officially designated health professional shortage area (HPSA).

Sanford Health Of Northern Minnesota

NOT APPLICABLE

93.912 - Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement

HRSA Office of Federal Assistance Management (OFAM) [HHS - HRSA]

Bemidji, Minnesota United States

City-Wide

Rural Health Network Development Program (HRSA-23-030)

Amendment Since initial award the total obligations have increased 95% from $295,727 to $575,685.